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A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that ¢â‚¬Å“she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.¢â‚¬ The nurse explains to the woman that:
- A. She will need to have her medications adjusted and be readmitted to the hospital for a complete workup.
- B. Limiting fluids can create imbalances in the body that can result in confusion; maybe we need to adjust the timing of your fluids.
- C. It is normal to be a little confused following surgery and it safe not to urinate at night.
- D. Confusion following surgery is common in the elderly due to loss of sleep.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You may also like to solve these questions
The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:
- A. Daily weight
- B. Serum sodium levels
- C. Measured intake and output
- D. Blood pressure
Correct Answer: A
Rationale: Daily weights show trends and can assist medical management by indicating if interventions and medications are effective. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the patient with fluid balance problems. However, if a patient is dehydrated, some laboratory data can show false elevations. Intake and output is extremely important, but matching the two is difficult because fluid is also lost through breathing, perspiration, stool, and surgical tubes. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by either depletion or excess of fluids in some situations.
A patient is receiving furosemide (Lasix) 40 mg/d IV. What electrolyte value should be monitored when a patient is receiving a loop diuretic?
- A. Calcium levels
- B. Phosphorous levels
- C. Potassium levels
- D. Magnesium levels
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse admitting a patient with a history of emphysema reviews her past lab reports and notes that the patient's PaCO2 has been 56 to 64 mmHg. The nurse will be cautious administering oxygen because:
- A. The patient's calcium will rise dramatically due to pituitary stimulation.
- B. The oxygen will increase the patient's intracranial pressure and create confusion.
- C. The oxygen may cause the patient to hyperventilate and become acidotic.
- D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?
- A. Tell the patient to rest more often.
- B. Tell the patient to stop taking the digoxin, and call the physician.
- C. Call the physician, report the symptoms, and request to draw a blood sample to determine the patient's potassium level.
- D. Tell the patient to avoid foods that contain caffeine.
Correct Answer: C
Rationale: Furosemide is a potassium-wasting diuretic. A low potassium level may cause weakness and palpitations. Telling the patient to rest more often won't help the patient if she's hypokalemic. Digoxin isn't causing the patient's symptoms, so she doesn't need to stop taking it. The patient should probably avoid caffeine, but this wouldn't resolve potassium depletion.
The nurse assessing skin turgor in an elderly patient should remember that:
- A. Overhydration causes the skin to tent.
- B. Dehydration causes the skin to appear edematous and spongy.
- C. Inelastic skin turgor is a normal part of aging.
- D. Normal skin turgor is moist and boggy.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.